Paget's dse of the nipple

Medullary Ca
Mucinous Ca
Papillary Ca
Tubular Ca
Invasive lobular Ca
Invasive Breast Ca
Invasive breast Ca have been described as lobular or
ductal in origin.
Early classifications used the term lobular to describe
invasive Ca that were assd w/ lobular Ca in situ, while
all other invasive cancers were referred to as ductal.
Paget's dse of the nipple
Frequently presents as a chronic, eczematous eruption of the
nipple, w/c may be subtle, but may progress to an ulcerated,
weeping lesion
Usually assd w/ extensive DCIS & may be assd w/ an invasive Ca
A palpable mass may or may not be present
Biopsy of the nipple will show a population of cells that are identical to the
underlying DCIS cells
Pathognomonic is the presence of large, pale, vacuolated cells (Paget's cells)
in the rete pegs of the epithelium.

Surgical therapy may involve lumpectomy, mastectomy, or

modified radical mastectomy, depending on the extent of
involvement & the presence of invasive Ca.
Medullary Ca
It accounts for 4% of all invasive breast Ca & is a
frequent phenotype of BRCA-1 hereditary breast Ca
Grossly, Ca is soft & hemorrhagic.
A rapid increase in size may occur 2o to necrosis &
hemorrhage.
On PE, it is bulky & often positioned deep w/in the
breast.
Bilaterality is reported in 20% of cases
Medullary Ca
Mucinous Ca
Accounts for 2% of all invasive breast Ca & typically
presents in the elderly population as a bulky tumor
It is defined by EC pools of mucin, w/c surround
aggregates of low-grade Ca cells.
5- & 10-year survival rates are 73 & 59%, respectively.
Ca cells may not be evident in all microscopy sections
because of the mucinous component
analysis of multiple sections is essential to confirm the
diagnosis of a mucinous Ca.
Papillary Ca
Accounts for 2% of all invasive breast Ca
Generally presents in the 7th decade of life & occurs in
a disproportionate number of nonwhite women.
It is small & rarely attain a size of 3 cm in diameter.
It defined by papillae w/ fibrovascular stalks &
multilayered epithelium.
It had 5- & 10-year survival rates similar to those for
mucinous & tubular Ca
Tubular Ca
Accounts for 2% of all invasive breast Ca.
It is reported in as many as 20% of women whose Ca
are diagnosed by mammography screening & is usually
diagnosed in the perimenopausal or early menopausal
periods.
Under LPM, a haphazard array of small, randomly
arranged tubular elements is seen.
Distant metastases are rare in tubular Ca & invasive
cribriform Ca.
Long-term survival approaches 100%.
Invasive lobular Ca
It accounts for 10% of breast Ca
The histopathologic features include small cells w/
rounded nuclei, inconspicuous nucleoli, & scant
cytoplasm
Special stains may confirm the presence of
intracytoplasmic mucin, w/ may displace the nucleus
(signet-ring cell carcinoma).
It is frequently multifocal, multicentric, & bilateral.
Because of its insidious growth pattern & subtle
mammography features, it may be difficult to detect.
Mammography
Ductography
USG
MRI
Mammography
Screening mammography is used to detect unexpected
breast Ca in asymptomatic women
Diagnostic mammography is used to evaluate women
w/abnormal findings such as a breast mass or nipple
discharge.
W/ screening mammography, 2 views of the breast are
obtained:
Mediolateral oblique (MLO) view images the greatest volume
of breast tissue, including the upper outer quadrant & the
axillary tail of Spence.
Craniocaudal (CC) view provides better visualization of the
medial aspect of the breast & permits greater breast
compression
Mammography
A diagnostic examination may use views that better define
the nature of any abnormalities, such as the 90-degree
lateral & spot compression views.
The 90-degree lateral view is used along with the CC view to
triangulate the exact location of an abnormality
Spot compression may be done in any projection by using a
small compression device, w/c is placed directly over a
mammography abnormality that is obscured by overlying
tissues
The compression device minimizes motion artifact, improves
definition, separates overlying tissues, & decreases the
radiation dose needed to penetrate the breast.
Mammography also is used to guide interventional
procedures, including needle localization & needle biopsy
Mammography
Specific mammography features that suggest a diagnosis of
a breast Ca include:
a solid mass w/or w/out stellate features, asymmetric
thickening of breast tissues, & clustered microcalcifications.
The presence of fine, stippled Ca in & around a suspicious
lesion is suggestive of breast Ca & occurs in as many as 50%
of nonpalpable Ca.
These microcalcifications are an especially important sign
of Ca in younger women, in whom it may be the only
mammography abnormality
Mammography was more accurate than clinical
examination for the detection of early breast Ca, providing
a true positive rate of 90%
Mammography
Only 20% of women w/ nonpalpable Ca had axillary
LN metastases, as compared to 50% of women w/
palpable Ca
Current guidelines of NCCN suggest that normal-risk
women age 20 yrs or older should have a breast exam
at least every 3 yrs.
At age 40 yrs, breast exams should be performed yearly
along w/ a yearly mammogram
Mammography
Xeromammography techniques are identical to those
of mammography w/ the exception that the image is
recorded on a xerography plate, w/c provides a positive
rather than a negative image
Details of the entire breast & the soft tissues of the chest
wall may be recorded w/ one exposure.
Mammography

Mammogram of a premenopausal breast

with a dense fibroglandular pattern
Mammography

Xeromammogram of the breast.

It allows visualization from the nipple to the
ribs
Mammography

Mammogram of a postmenopausal breast

w/ a sparse fibroglandular pattern
Mammography

Invasive breast cancer (arrow) shown in

the CC mammography
Mammography

Invasive breast cancer (arrow) shown in

the MLO mammography view
Mammography

Cone-compression mammography view of the Ca.

Note that the speculated margins of the cancer are
accentuated by cone compression.
Ductography
1o indication for ductography is nipple discharge,
particularly when the fluid contains blood.
Radiopaque contrast media is injected into one or more of
the major ducts & mammography is performed.
A duct is gently enlarged w/ a dilator & then a small, blunt
cannula is inserted under sterile conditions into the nipple
ampulla
Intraductal papillomas are seen as small filling defects
surrounded by contrast media
Ca may appear as irregular masses or as multiple intraluminal
filling defects.
Ductography

CC demonstrate a mass (arrows) posterior to the

nipple & outlined by contrast, w/c also fills the
proximal ductal structures.
Ductography

MLO mammography demonstrate a mass

(arrows) posterior to the nipple & outlined by
contrast, w/c also fills the proximal ductal
structures.
USG
Important method of resolving equivocal mammography
findings, defining cystic masses, & demonstrating the echogenic
qualities of specific solid abnormalities.
On ultrasound examination, breast cysts are well circumscribed, w/
smooth margins & an echo-free center
Benign breast masses usually show smooth contours, round or oval
shapes, weak internal echoes, & well-defined anterior & posterior
margins.
Breast Ca characteristically has irregular walls, but may have
smooth margins w/ acoustic enhancement.
It is used to guide FNAB, CNB, & needle localization of breast
lesions.
It is highly reproducible & has a high patient acceptance rate, but
does not reliably detect lesions that are 1 cm or less in diameter.
USG

CC mammography views show a large

lobulated mass
(breast cyst)
USG

MLO mammography views show a large

lobulated mass
(breast cyst)
USG

Ultrasound image of the mass shows it to be

anechoic w/a well-defined back wall,
characteristic of a cyst
USG

Craniocaudal mammography view of a

palpable mass (arrows).
(breast Ca)
USG

Ultrasound image demonstrates a solid mass

w/ irregular borders (arrows) consistent w/ Ca
MRI
There is current interest in using MRI to screen the
breasts of high-risk women & of women w/ a newly
diagnosed breast Ca.
In the 1st case, women w/ a strong family history of
breast Ca or who carry known genetic mutations require
screening at an early age, but mammography evaluation
is limited because of the increased breast density in
younger women.
In the 2nd case, a study of MRI of the contralateral
breast in women w/ a known breast Ca showed a
contralateral breast Ca in 5.7% of these women.